By Sri.Ananthakrishnan. P. S, President:
This is a complaint filed under section 12 of the Consumer Protection Act 1986.
2. The Complainant’s case in brief is as follows:-
The Complainant had joined in a Family Health Optima Insurance plan of Opposite Party as per policy No.P/181315/01/2018/003938 the validity of which is from 09.02.2018 to 08.02.2019. The Opposite Party had offered either cashless treatment or entire reimbursement of hospital expenses to the Complainant if, eligible. The Opposite Party told that one day admission in the hospital is sufficient to get the claim amount. The Complainant was admitted in Assumption Hospital on 08.10.2018 due to giddiness. He was admitted there as inpatient and after one day treatment, he was discharged with an advice to consult a neurologist. Then, on 10.10.2018, the Complainant went to Iqraa Hospital, Kozhikode. From there, CT-Cerebral Angiography and MRI Brain were taken and diagnosed that the Complainant has short segment minimal narrowing of the left vertebral artery, short segment moderate luminal narrowing of the left common carotid artery and tiny foci acute infarct in the left occipital lobe. The Complainant tried to get cashless treatment and the Opposite Party registered the claim and offered cashless treatment. The Complainant has given all the original treatment records and medical bills to Opposite Party. But Opposite Party has not provided cashless treatment and thus Complainant compelled to pay Rs.4,300/- to Assumption Hospital and Rs.12,844/- to Iqraa hospital, Kozhikode. Thereafter, the Opposite Party assured 100% reimbursement of these expenses. But, on 04.12.2018, the Complainant received a letter from the Opposite Party informing repudiation of his claim for the reason that he took treatment for ENT decease during the first year of policy. The repudiation is not with a valid reason. Believing the words of Opposite Party, the Complainant joined in the health insurance policy. Thus, the Opposite Party has a duty to reimburse the hospital expenses. So, the Complainant issued a letter to Opposite Party for reimbursement of the amount. The Opposite Party has committed unfair trade practice. Hence this complaint to get the reimbursement of hospital expenses with compensation and cost.
3. The Opposite Party filed version which in brief is as follows:-
They admitted that the Complainant took Family Health Optima Insurance plan from Opposite Party as stated in the complaint. At the time of availing the policy, the Complainant was supplied with the terms and conditions of the policy. The Opposite Party had received a pre-authorization request for the cashless treatment from Assumption Hospital which says that the Complainant was admitted in this hospital on 08.10.2018 for the complaints of labrynthitis. Labrynthitis is an inner ear infection that can affects a person’s balance and hearing. This means that the Complainant had taken treatment for ENT decease. As per Clause 3(ii)(a) of the policy condition, all treatment of deceases related to ENT are excluded for a period of first 2 years from the inception of policy. Since the present illness of the Complainant falls in this category, the Opposite Party is not liable to consider his claim. Hence they denied the cashless treatment and informed it to the Assumption Hospital and Complainant on 08.10.2018. The Complainant thereafter submitted claim along with discharge summary and bills for reimbursement. The discharge summary issued from Assumption Hospital shows that the Complainant was treated for BPPV (Benign Paroxysmal Positional Vertigo) and after the treatment, he was discharged on 09.10.2018. BPPV is a mechanical problem in inner ear which comes under ENT deceases. Therefore the same is to be excluded for a period of first two years as per clause 3(ii)(a) of the policy condition. Hence Opposite Party repudiated the claim as per letter dated 04.12.2018. After repudiation, the Complainant has sent a grievance letter and the Opposite Party sent reply letter on 29.12.2018. As per the norms, the insured are bound by the terms and conditions of the policy. Hence they denied the allegation that the Opposite Party is bound to give reimbursement to the Complainant. So also they denied that there is unfair trade practice from Opposite Party. Hence this complaint is to be dismissed with cost and compensation to the Opposite Party.
4. On the above contentions, the points raised for consideration are:-
1. Whether there is any unfair trade practice from the part of
Opposite Party?
2. If so, whether the Complainant is entitled to get any monitory
benefits from the Opposite Party?
3. Reliefs and Cost.
5. The evidence in this case consists of oral testimonies of PW1, OPW1, Ext.A1 to A5 and Ext. B1 to Ext.B8. Heard both sides.
6. Point No.1:- It is an admitted fact that the Complainant took a Family Health Optima Insurance Plan from the Opposite Party and it’s validity was from 09.02.2018 to 08.02.2019. There is no dispute with regard to the admission of Complainant in Assumption Hospital on 08.10.2018. It is evident that the Assumption Hospital forwarded a cashless treatment claim to Opposite Party which was denied by the Opposite Party for the reason that the Complainant was treated for ENT decease which is excluded for 2 years from the inception of policy. Ext. B3 and Ext. B4 are the request for the cashless treatment and Ext. B5 is the denial letter. It is an admitted fact that thereafter, the Complainant has given reimbursement claim with all documents and it was also repudiated for the same reason. Ext. B8 is the claim form and Ext. A4/B6 is the repudiation letter.
7. The specific case of the Complainant is that he was treated in Assumption hospital on 08.10.2018 and thereafter in Iqraa hospital on 10.10.2018. He filed this complaint for getting reimbursement of expenses of the treatment in Assumption hospital and Iqraa hospital. The Complainant has given Ext.B8 claim form to the Opposite Party for getting reimbursement of treatment expenses. But it is to be seen that though the allegation of the Complainant is that he put this reimbursement claim to get treatment expenses of Assumption Hospital, SulthanBathery and Iqraa Hospital, Ext.B8 Claim Form does not contain a claim for treatment expenses incurred by him from Iqraa hospital. Though it contains total treatment expenses, in Ext.B8, the Complainant did not state anything with regard to his treatment in Iqraa Hospital. Therefore, we need not consider here whether the Complainant is entitle to get the reimbursement of treatment expenses incurred in Iqraa hospital from the Opposite Party.
8. The next question is whether the Complainant is entitled to get reimbursement of treatment expenses in Assumption Hospital, Sulthan Bathery. The specific case of Complainant is that he was treated in Assumption Hospital, Sulthan Bathery for giddiness. The Complainant specifically stated in the complaint that he was treated in Assumption Hospital for not related to ear balancing. On the other hand, the specific case of Opposite Party is that the Complainant was treated for ENT decease in Assumption Hospital. Ext. B3 and Ext.B4 show that the Complainant was suffering from Labrynthitis. Ext.B2 is the discharge summary received by the Complainant from Assumption Hospital. It shows that the Complainant was treated for BBPV (Benign Paroxysmal Positional Vertigo). The specific case of the Opposite Party is that the Complainant was treated for ENT deceases and as per clause 3(ii) (a) of the policy condition, deceases of ENT are to be excluded for the first 2 years from the inception of the Optima Health Insurance Policy. Ext. B1 is the policy which includes terms and conditions. PW1 has given evidence claiming reimbursement. OPW1 has also given evidence denying the right of Complainant to get reimbursement. He stated that the Complainant is not entitled to get any reimbursement for treatment expenses since he was treated for ENT decease. PW1 deposed that the request for cashless treatment was denied by the Opposite party for the reason that his disease was ENT disease. OPW1 affirmed in the cross examination that they repudiated the reimbursement claim for the reason that the disease of Complainant was ENT disease. Even though, the Opposite Party has affirmed that both these diseases are ENT diseases, the Complainant has not taken any pain to prove that these are not ENT diseases by examining an expert. Medical dictionary shows that labrynthitis as well as BPPV are deceases affected to inner ear. So, we have no hesitation to hold that the Complainant was treated for ENT disease. No doubt the Complainant has taken the policy from 09.02.2018 and he was admitted in hospital on 08.10.2018. So he was treated within 2 years from the inception of policy.
9. As I stated, as per clause 3 (ii) (a) of policy condition, a waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the treatment of diseases of ENT. Therefore it is clear from the terms and conditions of the policy, an insured is not entitled to get cashless treatment or reimbursement of the treatment expenses, if he treated for ENT decease. So the repudiation of the claim of the Complainant by the Opposite Party is valid and therefore the Complainant is not entitled to get reimbursement of the treatment expenses in Assumption Hospital, Sulthan Bathery. Hence point No.1 is found against the Complainant.
10. Point No.2 &3:- Since, Point No.1 is found against the Complainant, he is not entitled to get any reliefs as prayed for.
In the result, the complaint is dismissed without costs.
Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 23rd day of June 2022.
Date of Filing:-04.02.2019.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
APPENDIX.
Witness for the complainant:-
PW1. Biju Jose. Driver.
Witness for the Opposite Party:-
OPW1. Balu. M. Assistant Manager.
Exhibits for the Complainant:-
A1. Family Health Optima Insurance Plan for the period of 09.02.2018 to
08.02.2019.
A2. MRI brain Report. Dt:10.10.2018.
A3. CT-Cerebral Angiography Report. Dt:10.10.2018.
A4. Repudiation Letter. Dt:04.12.2018.
A5. Repudiation Letter. Dt:29.12.2018.
Exhibits for the Opposite Party:-
B1. Copy of Policy Schedule and Conditions.
B2. Copy of Discharge Summary from Assumption Hospital, Sulthan
Bathery.
B3. Copy of Request for Cashless Hospitalization for medical insurance
policy.
B4. Copy of Request for Cashless Hospitalization for medical insurance
policy.
B5. Copy of Denial of Pre-Authorization Request for Cashless Treatment.
Dt:08.10.2018.
B6. Copy of Repudiation Letter. Dt:04.12.2018.
B7. Authorization Letter. Dt:04.09.2021.
B8. Claim Form. Dt:09.11.2018.
PRESIDENT :Sd/-
MEMBER :Sd/-
MEMBER :Sd/-
/True Copy/
Sd/-
ASSISTANT REGISTRAR
CDRC, WAYANAD.
